Leadership and governance

Stewardship is the most complex but also crucial component of any health system. It is about the role of the government in health and its relation to other actors whose activities impact on health. Both political and technical expertise is required to address competing demands for limited resources, but there is no blueprint or single, fixed approach for effective health leadership and governance. Key components include policy guidance, information and oversight, collaboration and coalition building, regulation, system design, and accountability.

As weak leadership and poor governance are some of the defining characteristics of fragile states; health sector policies in these contexts are frequently ill-defined, while regulation and oversight in a powerless and possibly corrupt system are not very effective. In these contexts, where there are frequently high levels of aid dependency, donors have been key in the development and support of strategies to improve leadership and governance capacity of ministry staff, who carry ultimate responsibility for stewardship of the health system together with other ministries such as the Ministry of Finance, Parliaments and their committees, and other levels of government. In failed states UN agencies, NGOs and technical consultants are often in the driving seat.

An increasing range of instruments and institutions have been developed to carry out the range of functions required for effective leadership, management and governance, although many of these are weak or poorly developed in fragile states, and the capacity to implement them is limited. In the (early) reconstruction phase, health ministries are generally assisted with the development of (sector) policies and medium-term expenditure frameworks for an equitable standardised package of care in order to ensure the best possible results according to available resources.